A nurse is caring for a client who is 1 day postoperative following an open thoracotomy. The client is receiving oxygen mist at 40% by face tent. The client's SPO2 is 89-96%. ABG results are: pH 7.31, PaO2 93 mm Hg, PCO2 5O mm Hg, HCO3 25 mEq/L. Which of the following is an appropriate action by the nurse?
Position the client prone and have the respiratory therapist perform postural drainage.
Place the client in high-Fowler's position and encourage the use of incentive spirometer and coughing.
Increase oxygen to 70%.
Switch oxygen to a nonrebreather mask.
The Correct Answer is B
A. Prone positioning and postural drainage are typically not appropriate interventions for a client 1 day postoperative following an open thoracotomy, as this could place stress on the incision site and cause discomfort or injury.
B. High-Fowler's position facilitates lung expansion, which can improve ventilation and oxygenation. Encouraging the use of an incentive spirometer and promoting coughing helps clear secretions and expand the lungs, addressing the mild respiratory acidosis indicated by the ABG results (pH 7.31 and PaCO2 50 mm Hg).
C. Increasing oxygen to 70% is not appropriate, as the PaO2 level is within normal limits (93 mm Hg). The client's issue appears to be related more to ventilation (indicated by the elevated PaCO2) rather than oxygenation, so additional oxygen would not address the underlying cause and could lead to oxygen toxicity if used long-term.
D. A nonrebreather mask delivers a high concentration of oxygen, which is not necessary in this case since the client’s PaO2 is already adequate. The primary issue is not a lack of oxygen but rather the retention of CO2, so promoting ventilation and lung expansion through positioning and respiratory exercises is more appropriate.
Nursing Test Bank
Naxlex Comprehensive Predictor Exams
Related Questions
Correct Answer is A
Explanation
A. Electrical burns can have small amounts of skin damage, but more extensive damage beneath the skin.
This response is the best choice because it educates the client about the potential for deeper tissue damage associated with electrical burns. It acknowledges that while the burn on the skin may appear small, the damage underneath could be more extensive, affecting muscles, nerves, and blood vessels.
B. Electrical burns commonly cause reddened/purplish skin without blistering.
This statement is not the best response because it focuses solely on the appearance of the skin without addressing the potential for deeper tissue damage. While it is true that electrical burns can present with reddened or purplish skin without blistering, this response does not provide comprehensive information about the nature and severity of electrical burns.
C. Electrical burns typically are minor.
This response is incorrect because it downplays the seriousness of electrical burns. While some electrical burns may indeed be minor, others can cause significant tissue damage and complications. It's important for the nurse to educate the client about the range of severity that electrical burns can present.
D. Electrical burns usually cause much more skin damage than what can be seen on your skin.
This statement is partially accurate but does not provide as much information as choice A. While it acknowledges that electrical burns can cause more damage than what is visible on the skin's surface, it doesn't emphasize the potential for deeper tissue damage as effectively as choice A does.
Correct Answer is D
Explanation
A. Elevation of the head of the bed by 30 degrees: While elevation of the head of the bed may be necessary for certain medical conditions, it is not the priority concern in a client with a gasoline burn. Decontamination and assessment of the burn injury take precedence.
B. Determining the amount of gasoline that the client encountered: While it's important to gather information about the circumstances of the injury, including the amount of gasoline involved, this is not the priority concern at the immediate moment. Decontamination and assessment of the burn take precedence over obtaining historical information.
C. Asking the client when they last ate a meal: While assessing the client's nutritional status and potential need for dietary interventions is important, it is not the priority safety concern in the context of a gasoline burn. Decontamination and assessment of the burn injury are more critical at this time.
D. Decontamination of the client
When a client sustains a gasoline burn, the priority safety concern is to decontaminate the client. Gasoline can cause chemical burns and can be absorbed through the skin, leading to systemic effects. Therefore, it's crucial to remove any remaining gasoline from the client's skin and clothing to prevent further absorption and minimize the risk of complications.
Whether you are a student looking to ace your exams or a practicing nurse seeking to enhance your expertise , our nursing education contents will empower you with the confidence and competence to make a difference in the lives of patients and become a respected leader in the healthcare field.
Visit Naxlex, invest in your future and unlock endless possibilities with our unparalleled nursing education contents today